Shedding light on the "dark side"

When this physician became an HMO administrator, other doctors treated him as if he were Darth Vader. But it's not all bad, he reports.

By Stephen E. Jacobs, MD
Pediatrician, Modesto, CA

"Hi, my name is Steve and I'm an HMO administrator." I'd probably be better accepted at a medical society meeting if I lied and said I was an alcoholic or a drug addict.

I left a thriving pediatric practice to go to work for "the enemy." Friends and colleagues ask me how I could do such a foolish thing. While they say I've gone over to the dark side, I believe that the opposite is true.

I wasn't an advocate of HMOs when I started out in medicine. I spent 10 years in a solo practice providing totally unmanaged care. Then I helped form a pediatric group, and we contracted with managed care plans. During that time, I realized that HMOs are actually good for kids. I've seen countless children who didn't get the care they needed because their families couldn't afford the deductible or the 20 percent of the bill that their indemnity insurance or PPO didn't cover. By requiring only a small copayment and covering all necessary care, HMOs really helped my young patients. By working well with managed care plans, I also made a very decent living.

It's one thing to appreciate HMOs, but quite another to leave practice and switch sides. Why did I do it? First, while I love working with kids, I could imagine a time when a day full of otitis, diaper dermatitis, and ADHD would be no fun anymore. Second, I've always been interested in building organizations and making them work better. Finally, I was tired of the doctors' lounge refrain: "If I were running that HMO, things would be different." Unlike those who only complained, I wanted to make health care work better for my community. I welcomed the challenge.

When the Kaiser Permanente HMO went looking for a community physician to become an administrator two years ago, I applied for and got the job. While Kaiser typically operates clinics with employed physicians, in Modesto it has a network of independent physicians, and I help run it.

What is a typical day like for a physician administrator? I review referrals to assure that they are appropriate, and I supervise provider reimbursement. This includes not only assuring that doctors are paid on time, but also that Kaiser is not paying for "creative" coding. By the way, I've found that most wrong codes are the result of simple errors: Doctors and their staffs simply need education in the fine points of the CPT system.

Part of my day is devoted to helping doctors arrange for specialized care, often on an emergency basis. The northern California Kaiser system employs nearly every kind of tertiary specialist imaginable, but our network physicians neither know them nor know how to find them. Putting the local doctors in touch with the right people is my responsibility.

Quite a bit of what I do is less pleasant, however. I'm the guy that the community doctors yell at when they're angry. It isn't much fun, but I'm learning to control my own temper. Often after a physician finishes "venting," we have a useful dialogue. Recently I received a call from a local physician who was irate because we'd refused to authorize an MRI. I found that confusing because our health plan doesn't require permission to order these scans. When he gave me the patient's name, I discovered she wasn't in our system; he was complaining to the wrong health plan. I'm hoping that because I was nice about it, he might feel better disposed toward my HMO.

Personal relationships do have an impact on how physicians regard particular plans. After diatribes about the evils of managed care in general, several doctors have informed me that, while they hate health plans, they hate mine a bit less than the others. I guess that's better than nothing!

Special projects are the most unusual part of my job. Shortly after starting with Kaiser, I helped extend its laboratory system into our community. My job was to look at our lab from a physician perspective, to get comments from other doctors, and to deal with day-to-day problems in the interactions between the lab and a hundred small offices. Now I'm part of a team that's developing a new medical center, including a 200-bed hospital. It's an exhilarating opportunity.

I'm often asked whether I miss taking care of kids. In fact, I still take care of them. At Kaiser Permanente, every physician administrator sees patients; I practice 30 percent of the week. I enjoy it immensely, though not being full time, I worry about losing clinical skills. Will I miss something on a physical exam because I'm out of practice?

On the other hand, my administrative work has reintroduced me to the world of adult medicine. Reading progress notes and procedure reports, I've learned what life is like for members of almost every medical specialty.

Since I joined Kaiser, it's been challenging to deal with the doctors I've known socially for the last 20 years. Few have been openly hostile except when they were in the midst of a particularly stressful situation. Some remain good friends. But in the majority of interactions, doctors tend to be coolly polite.

Despite the gulf that has opened between me and many of my colleagues, I'm happy with my decision to become an HMO administrator. There are disadvantages, like working in a bureaucratic organization, spending too much time in meetings, and getting yelled at by angry physicians. But I have new challenges every day.

Many physicians ask me, "Just what do you do all day?" It's as if they don't think an HMO executive is capable of doing anything except sitting at a desk and saying "No." But it's amazing how often the next words out of their mouths—often whispered—are: "How could I get a job like yours?"

 

Stephen Jacobs. Shedding light on the "dark side". Medical Economics 2003;6:74.